ChoiceONE Select - Plan A Options and Benefits

Basic Core Benefits - Plan A

The basic core benefits for Plan A, including Medicare (PART A) - Hospital Services - Per Benefit Period , Medicare (PART B) - Medical Services - Per Calendar Year , and Part A&B , shall consist of the following:

A. coverage for Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

B. coverage for Part A Medicare Eligible Expenses, to the extent not covered by Medicare, incurred as daily hospital charges during use of Medicare lifetime hospital inpatient reserve days;

C. upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of the Medicare Part A eligible expenses for hospitalization paid at the diagnostic related group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days;

D. coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulation) unless replaced in accordance with federal regulation; and

E. coverage for the coinsurance amount (or in the case of hospital outpatient department services, the copayment amount) of Medicare Eligible Expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible;

F. SOME RESTRICTIONS, LIMITATIONS AND EXCLUSIONS apply.

The basic core benefits are summarized in the following tables:

PLAN A MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. $0 Indicates your liability for covered charges. You are responsible for all other non-covered charges. **If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare.
SERVICE	TYPE	MEDICARE PAYS	PLAN PAYS	YOU PAY
HOSPITALIZATION, ** Semiprivate room and board, general nursing and miscellaneous services and supplies
	First 60 days	All but $1068	$0	$1068 (Part A Deductible)
	61st through 90th day	All but $267 a day	$267 a day	$0**
	91st day and after: While using 60 lifetime reserve days	All but $512 a day	$512 a day	$0**
	91st day and after: Once lifetime reserve days are used. Additional 365 lifetime days	$0	100% of Medicare Eligible Expenses	$0**
	91st day and after: Once lifetime reserve days are used. Beyond the additional 365 days	$0	$0	All costs
SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital
	First 20 days	All approved amounts	$0	$0**
	21st through 100th day	All but $133.50 a day	$0	$Up to $133.50 a day
	101st day and after	$0	$0	All costs
BLOOD***
	First 3 pints	$0	3 pints	$0**
	Additional amounts	100%	$0	$0**
HOSPICE CARE
	Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for outpatient drugs and inpatient respite care	$0	Balance

PLAN A MEDICARE (PART B) - MEDICAL SERVICES PER CALENDAR YEAR Once you have been billed $131 of Medicare-Approved amounts for covered services, your Part B Deductable will have been met for the calendar year. $0 Indicates your liability for covered charges. You are responsible for all other non-covered charges. **If you do not use a Network Provider, you are responsible for all charges not paid by Medicare.
SERVICE	TYPE	MEDICARE PAYS	PLAN PAYS	YOU PAY
MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,*** such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable medical equipment
	First $135 of Medicare-Approved Amounts*	$0	$0	$135 (Part B Deductible)
	Remainder of Medicare-Approved Amounts	Generally 80%	Generally 20% (or in the case of hospital outpatient department services, applicable copayments)	$0**
	Part B Excess Charges (Above Medicare-Approved Amounts)	$0	$0	All costs
BLOOD***
	First 3 pints	$0	All costs	$0**
	Next $135 of Medicare-Approved Amounts*	$0	$0	$135 (Part B Deductible)
	Remainder of Medicare-Approved Amounts	80%	20%	$0**
CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES
	N/A	100%	$0	$0**

GENERAL LIMITATIONS AND EXCLUSIONS

This Health Plan does not cover any expenses of the type excluded by Medicare or not covered under the terms of this Health Plan. UTMB HP, INC. will pay full benefits under this Health Plan if you are treated by a Network Provider. If you incur Medicare Eligible Expenses for the services of a Non-network Provider, the Medicare program may provide coverage; however, no coverage will be provided under this Health Plan. Please see Provider Restrictions and Medicare Restrictions for details.

Provider Restrictions:

· The Health Plan does not restrict payment of benefits for Covered Services unless they are provided by a Non-network Provider, with certain exceptions noted below.

· Neither Part A nor Part B benefits under this Health Plan will be paid for either Hospital or Medical Services if those services are provided by a Non-network Provider.

These restrictions will not apply for Medicare Eligible Expenses if:

1. the services are for symptoms requiring Emergency Care or are immediately required for an unforeseen illness, injury, or a condition, and, it is not reasonable to obtain such services through a Network Provider; or

2. the services are not available through Network Providers.

Payment of benefits for Emergency Care or for services immediately required for an unforeseen illness or injury is conditioned on your obtaining Emergency Care or such services through Network Providers if it is reasonable to do so. You must notify UTMB HP, INC. within 48 hours or as soon as reasonably possible after you receive Emergency Care. Unless pre-approved by the Health Plan, the Health Plan does not cover follow-up or post-stabilization care provided by Non-network Providers. Services that are not available through Network Providers must be pre-authorized by the Health Plan before benefits will be paid under this Health Plan. Some Covered Services are subject to utilization management and pre-authorization. Network Providers and their locations are listed in the Provider Directory.

Medicare Restrictions:

Except as provided in the Schedule of Benefits, coverage does not include payment of benefits for any items that are not both Medicare Approved Amounts and Medicare Eligible Expenses. To the extent that Medicare copayments, deductibles, coinsurance, benefit periods, maximum benefits, or other such provisions vary from those specified in this Schedule of Benefits (such as for certain mental health services), Medicare provisions shall govern coverage under this Schedule of Benefits.